Liver chemistries in severe or non-severe cases of COVID-19: A systematic review and meta-analysis

BACKGROUND

Coronavirus disease (COVID-19) patients exhibit different patterns of liver impairment, according to growing evidence.

AIM

In this study, we sought to provide a comprehensive analysis of liver test parameters in patients with severe and non-severe COVID-19.

METHODS

We performed a meta-analysis of published liver manifestations and described the liver damage in COVID-19. We searched PubMed, Google Scholar, Embase, Cochrane Library, medRxiv, bioRxiv, and three Chinese electronic databases through April 18, 2020, in accordance with the Preferred Reporting Items for Meta-Analyses. We analyzed pooled data on liver chemistries stratified by COVID-19 severity using a fixed or random-effects model.

RESULTS

A meta-analysis of 56 studies, including 11052 patients, found that the pooled mean alanine aminotransferase (ALT) in severe COVID-19 cases was 35.9 IU/L whereas in non-severe COVID-19 cases was 27.3 IU/L. Average aspartate aminotransferase (AST) levels were 44.3 IU/L in severe cases compared to 27.9 IU/L in non-severe cases. In addition, AST levels are often higher than ALT levels regardless of disease severity. The severe cases tended to have a higher gamma-glutamyltransferase level but a lower albumin level than the non-severe cases.

CONCLUSION

Severe COVID-19 was more likely to be associated with abnormal liver test results. Monitoring liver chemistry closely can help detect disease progression early.

Risk factors and outcomes for acute-on-chronic liver failure in COVID-19: a large multi-center observational cohort study

Objective

Coronavirus disease 2019 [COVID-19] infection in patients with chronic liver disease [CLD] may precipitate acute-on-chronic liver failure [ACLF]. In a large multi-center cohort of COVID-19-infected patients, we aim to analyze (1) the outcomes of patients with underlying CLD [with and without cirrhosis] and (2) the development and impact of ACLF on in-hospital mortality.

Design

We identified 192 adults with CLD from among 10,859 patients with confirmed COVID-19 infection (admitted to any of 12 hospitals in a New York health care system between March 1, 2020 and April 27, 2020). ACLF was defined using the EASL-CLIF Consortium definition. Patient follow-up was through April 30, 2020, or until the date of discharge, transfer, or death.

Results

Of the 84 patients with cirrhosis, 32 [38%] developed ACLF, with respiratory failure [39%] and renal failure [26%] being the most common. Hispanic/Latino ethnicity was particularly at higher risk of in-hospital mortality [adjusted HR 4.92, 95% 1.27–19.09, p < 0.02] in cirrhosis despite having lower risk of development of ACLF [HR 0.26, 95% CI 0.08–0.89, p = 0.03]. Hypertension on admission predicted development of ACLF [HR 3.46, 95% CI 1.12–10.75, p = 0.03]. In-hospital mortality was not different between CLD patients with or without cirrhosis [p = 0.24] but was higher in those with cirrhosis who developed ACLF [adjusted HR 9.06, 95% CI 2.63–31.12, p < 0.001] with a trend for increased mortality by grade of ACLF [p = 0.002]. There was no difference in in-hospital mortality between the CLD cohort compared to matched control without CLD (log rank, p = 0.98) and between the cirrhosis cohort compared to matched control without cirrhosis (log rank, p = 0.51).

Conclusion

Development of ACLF is the main driver of increased in-hospital mortality in hospitalized patients with COVID-19 infection and cirrhosis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12072-021-10181-y.

Is testing of aspartate aminotransferase necessary along with every alanine aminotransferase for health check in elderly individuals?

OBJECTIVE

This study is to evaluate whether Aspartate Aminotransferase (AST) is necessary to screen for liver function in apparently healthy elderly individuals.

METHODS

We derived the proportions of elevated ASTs that would not be measured based on 2018-year of paired Chinese elderly (Age ≥ 65 years old) check-up. Defined as AST > 40U/L is elevated. The relationship between alanine aminotransferase (ALT) and AST was analyzed by using Pearson's approach. Receiver operating characteristics curve analysis was used to evaluate the predictive accuracy of ALT for abnormal AST.

RESULTS

52,857 pairs of ALT and AST were analyzed. Serum AST was found to be positively correlated with serum ALT, r = 0.81, p < 0.01 for the entire cohort. The receiver operating characteristics (ROC) curve of ALT for predicting positive AST is 0.918. The optimal threshold for ALT is 28 U/L with the sensitivity of 82.6%, and specificity of 86.8%. At the threshold, below 0.7% of subjects with positive AST were missed, but approximately 83% of the AST tests were eliminated.

CONCLUSION

Our study showed that tests of AST were not necessary along with every ALT test for health check in elderly individuals. An estimated 84.5% of subjects were not needed for AST tests which could have saved about CN¥ 815 million (USD$115 million or EURO$100 million) every year.

Misclassification of chronic hepatitis B natural history phase: Insight from new ALT, AST, AKP, and GGT reference intervals in Chinese children. Clin Chim Acta. 2019;489:61-67. [PMID: 30503274 DOI: 10.1016/j.cca.2018.11.034]

BACKGROUND

The age- and sex-specific reference intervals (RIs) for liver chemistry in children are not available in China. Our study aimed to establish age and gender related RIs for ALT, AST, AKP, and GGT in China, and apply the new RI for ALT in children with chronic hepatitis B to use as a biochemical marker for disease progression.

METHODS

Data were collected from the Children's Healthcare Center. The measurements of ALT, AST, AKP and GGT were performed on a Hitachi 7600 Chemistry Analyzer. Age- and sex-specific RIs were determined using a percentile (3rd-97th) method. The sensitivity and specificity were determined to test the ability of the newly proposed ALT thresholds to classify children with chronic HBV infection.

RESULTS

The age- and sex-specific RIs of ALT, AST, AKP and GGT were established based on 4232 Chinese healthy children. Using the new median ALT threshold, the sensitivity was higher. The detection of chronic HBV infection was 31.2% in boys and 35.5% in girls, while a very slight decrease in specificity was found. Based on the newly proposed RIs of ALT, approximately 16.1% boys and 19.0% girls would be classified in the HBeAg-positive chronic hepatitis phase, but using the current ALT threshold of children's hospitals they were in HBeAg-positive chronic infection phase.

CONCLUSIONS

Based on a large healthy population, we established the sex- and age-specific RIs of ALT, AST, AKP and GGT serum activities for Chinese children. Meanwhile, newly proposed liver chemistry RIs will benefit the understanding of liver function and the natural history of chronic HBV infection in children.

[The medical laboratory issues about recommendation on uniform cutoff values of "Normal" ALT in the ACG guidelines]

In the recent clinical guidelines dealing with laboratory tests for liver disease evaluation, the American College of Gastroenterology (ACG) recommends ALT upper reference limits of 33 U/L for males and 25 U/L for females, and individuals with results above these "normal" cutoffs should be further investigated. Considering the differences between laboratory assays measuring ALT in our country, the uniform ACG "normal" range may not be suitable for Chinese population. On the other hand, reference upper/lower limits should not be equated with clinical decision thresholds. Simply acting in accordance with the reference range from ACG guidelines for ALT may lead to overdiagnosis and unnecessary follow-up examinations.